Treatment Pathways For Patients Research Articles

Factors influencing surgical treatment of De Quervain's tendinopathy: A retrospective cross-sectional observational study

BackgroundThe literature surrounding how different patient, sociodemographic, and anatomical factors influence surgical treatment of De Quervain's tendinopathy (DQT) is limited. PurposeWe hypothesised that different patient, anatomical, or sociodemographic factors influence the management of DQT with regard to non-operative vs. surgical management. MethodsThis retrospective cross-sectional study reviewed 155 cases of patients with DQT seen over a 10 year period. Patient-specific factors included age, gender, hand affected, dominant hand, steroid injection given and mean number of injections. Sociodemographic factors included ethnicity, employment, and deprivation, were measured using deprivation quintiles through The Index of Multiple Deprivation. Anatomical factors included the presence of subcompartmentalization, number of APL and EPB tendon slips, tendon thickening, exudative tenosynovitis, hypervascularization, and the presence of a sheath ganglion Patients were categorized into either non-operative or surgical cohort. Bivariate analysis was used to compare factors between the cohorts, and significant factors (p < 0.05) were included in the logistic regression model, used to predict factors influencing surgical management. ResultsBivariate analysis detected a significant difference in the mean number of steroids given between the non-operative and surgical cohort (p = 0.001) patient factors. For sociodemographic factors, a significant difference was found between deprivation quintiles (p = 0.02). From the anatomical factors, the surgical cohort had more patients with multiple APL tendon slips (p = 0.02) and the presence of a tendon ganglion sheath ganglion (p = 0.02). For patient and sociodemographic factors, logistic regression identified that the number of steroids (per patient) and being in deprivation quintile 4 were associated with surgical treatment. For anatomical factors, multiple APL tendon slips and the presence of a tendon sheath ganglion were associated with the surgical treatment. ConclusionThis study suggests that several factors are associated with the need for surgical treatment of DQT, including the number of steroid injections received, social deprivation, and anatomical factors, such as the presence of multiple tendon slips and a tendon sheath ganglion. Our findings add to the growing body of literature exploring factors that may influence treatment pathways for patients with DQT.

A telemedicine-enabled intravenous thrombolytic treatment pathway for patients with hyperacute non-arteritic central retinal artery occlusion

PurposeTo describe the visual acuity (VA) outcomes from a telemedicine-enabled pathway allowing for rapid diagnosis and administration of intravenous (IV) thrombolytic treatment for non-arteritic central retinal artery occlusion (naCRAO) within 4.5 hours (4.5 h) of visual loss. DesignRetrospective observational case series. MethodsSetting: A large managed healthcare consortium.Patient Population: Eighty-five patients with naCRAO and vision loss for less than 4.5 h presenting between 2021 and 2023. Thirty-five patients received IV thrombolytic therapy and 50 patients were closely observed.Intervention: A collaborative telemedicine-enabled pathway employing fundus photography was previously established by Ophthalmology, Emergency Medicine, and Stroke services to rapidly evaluate and manage patients presenting with acute painless monocular vision loss and allow for administration of IV tenecteplase (0.25 mg/kg) for eligible consenting patients diagnosed with naCRAO within 4.5 h. Retrospective chart review was conducted to collect data on demographics, vascular risk factors, clinical features, VA outcomes, and adverse events. Comparison was made between patients who received intravenous thrombolysis and those who were observed.Main Outcome Measures: Improvement in VA of at least 0.3 logarithm of the minimum angle of resolution (logMAR) and/or from 20/200 or worse to 20/100 or better. ResultsA greater percentage of patients in the treated group had VA improvement of ≥0.3 logMAR (54.3 % vs 28 %, p = .014), and a greater percentage of patients in the untreated group had VA worsening of ≥0.3 logMAR (30 % vs 5.7 %, p = .006). Twice the percentage of treated versus untreated patients had improved VA from 20/200 or worse to 20/100 or better, but this difference was not statistically significant (20 % vs 10 %, p = .192). There was a significantly shorter mean time to treatment for those patients who had VA improvement from 20/200 or worse to 20/100 or better compared to those who did not (118 versus 171 min, p = .031). Two patients experienced intracranial bleeding after IV thrombolysis. ConclusionsThe evaluation and treatment of hyperacute naCRAO is possible on a large scale via an integrated telemedicine-enabled approach utilizing fundus photography. The use of IV thrombolytic was associated with better VA outcomes compared to observation alone. Prospective randomized controlled trials are needed to confirm these findings and determine optimal management.

Uterine fibroids with heavy menstrual bleeding stratified by race in a commercial and Medicaid database

BackgroundHistorically, the clinical characteristics and treatment pathways for patients with uterine fibroids and heavy menstrual bleeding have differed between White and Black women. ObjectiveTo provide a contemporary comparison of patient characteristics and treatment patterns among White and Black women with uterine fibroids and heavy menstrual bleeding in the United States. Study DesignThis retrospective cohort study included administrative claims data from 46,139 White and 17,297 Black women with uterine fibroids and heavy menstrual bleeding from the Optum Clinformatics database (January 2011–December 2020) and 7353 White and 16,776 Black women from the IBM MarketScan Multi-State Medicaid Insurance database (January 2010–December 2019). Patients were indexed at their initial uterine fibroid diagnosis claim and were required to have a claim for heavy menstrual bleeding and ≥12 months of continuous enrollment pre- and postindex. Patients were followed until the earliest of death, disenrollment, hysterectomy date, or end of study database. Outcomes were stratified by race and included patient demographics, clinical characteristics, pharmacologic treatment patterns, and surgeries/procedures. Pearson's Chi-square test for categorical variables and Student's t-test for continuous data were used to evaluate differences in baseline characteristics. Descriptive statistics were used to characterize treatment pathways for hormonal contraceptive use in women with ≥24 months of follow-up. Kaplan–Meier survival analysis was used to estimate time until hysterectomy, with log-rank testing to assess between-group differences. ResultsThe mean (standard deviation) duration of follow-up was 44.6 (27.9) and 41.0 (24.9) months in the commercial and Medicaid databases, respectively. Mean (standard deviation) age at uterine fibroid diagnosis was lower for Black than White women in both databases (commercial: 42.3 [6.5] vs 44.4 [6.3] years; P<.0001; Medicaid: 39.6 [7.1] years vs 40.2 [7.2] years; P<.0001). Anemia was more prevalent in Black vs White women in both databases (commercial: 5.9% [1028/17,297] vs 3.6% [1648/46,139]; P<.0001; Medicaid: 7.0% [1180/16,776] vs 4.5% [331/7353]; P<.0001). In the commercial database, approximately one-half of women had claims for ≥1 bulk symptom, with no significant differences between groups. In the Medicaid database, significantly more White than Black women had claims for bulk symptoms (77.0% [5665/7353] vs 68.4% [11,477/16,776]; P<.0001). Approximately 40% of all patients received hormonal drug therapies as initial treatment, most commonly hormonal contraceptives. However, discontinuation of hormonal contraceptive therapy was nearly universal, with one-half discontinuing within a median treatment duration of ∼5 months. Most women stopped treatment after 1 or 2 agents (commercial: White, 89.9% [9757/10,857]; Black, 90.0% [3594/3993]; Medicaid: White, 92.2% [1635/1773]; Black, 94.2% [4454/4726]). Hysterectomy was the most common procedure, and was more common among White vs Black women (commercial: 43.9% [20,235/46,139] vs 37.8% [6536/17,297]; Medicaid: 46.8% [3444/7353] vs 32.0% [5364/16,776]). ConclusionsBlack women with UF-HMB were diagnosed at a younger age than White women, and White women had higher hysterectomy rates than Black women, representing a shift from earlier researched treatment patterns. Patients with UF-HMB were also highly reliant on hormonal contraceptives, followed by nearly universal therapeutic discontinuation.

Prevalence, incidence, and treatment of dyslipidemia in patients with high or very high cardiovascular risk in Germany

Background2019 ESC/EAS guidelines on management of dyslipidemia outline treatment goals of LDL-C reduction in patients with high and very high cardiovascular (CV) risk. ObjectiveTo describe the proportion, clinical characteristics, and treatment practices of adult patients with dyslipidemia and high or very high CV risk in Germany. MethodsBased on German claims data from 2010-2019, a retrospective cross-sectional study on prevalence, incidence, and treatment pathways in patients with dyslipidemia and high and very high CV risk is performed. ResultsBetween 2010 and 2019, there were 213 to 233 adult patients per 1,000 with prevalent dyslipidemia based on ICD 10 codes. Annual incidence ranged from 31.7 to 40.2 per 1,000. In 2019, 1.2% and 22.8% of the prevalent patients are classified to high or very high CV risk. Out of these patients, 61.7% and 78.5% received lipid lowering treatments (LLT). Among incidence patients, prescription rates are further apart between high-risk and very-high-risk patients, at 56.6% and 79.2%. Cross-sectional analysis showed that in 2019 statin monotherapy is the most common LLT (87.2%) administered mainly at moderate dose (59.9%). In that year, 2.7% and 8.4% of the patients received ezetimibe as monotherapy or in combination with statins. The proportion of treatment pause, or discontinuation was 56.6% over time, with subsequent re-initiation for 42.0% of patients. ConclusionsAnalysis indicates that despite recommendations, intensive treatment therapies are underutilized in clinical practice even in high and very high CV risk patients with primary hypercholesterolemia/mixed dyslipidemia, who may have benefited from LLT optimization.

Estimation of two-year hospital costs of hip and knee periprosthetic joint infection treatments using activity-based costing.

Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months. Using admission and procedure data from a prospective observational cohort in Australia and New Zealand, Australian Refined Diagnosis Related Groups were assigned to each admitted patient episode of care for activity-based costing estimates of 273 hip PJI patients and 377 knee PJI patients. Costs were aggregated at 24 months post-diagnosis, and are presented in Australian dollars. The mean cost per hip and knee PJI patient was $64,585 (SD $53,550). Single-stage revision mean costs were $67,029 (SD $47,116) and $80,063 (SD $42,438) for hip and knee, respectively. Two-stage revision costs were $113,226 (SD $66,724) and $122,425 (SD $60,874) for hip and knee, respectively. Debridement, antibiotics, and implant retention in hips and knees mean costs were $53,537 (SD$ 39,342) and $48,463 (SD $33,179), respectively. Suppressive antibiotic therapy without surgical management mean costs were $20,296 (SD $8,875) for hip patients and $16,481 (SD $6,712) for knee patients. Hip patients had 16 different treatment pathways and knee patients had 18 treatment pathways. Additional treatment, episodes of care, and length of stay contributed to substantially increased costs up to a maximum of $369,948. Treating PJI incurs a substantial cost burden, which is substantially influenced by management strategy. With an annual PJI incidence of 3,900, the cost burden would be in excess of $250 million to the Australian healthcare system. Treatment pathways with additional surgery, more episodes of care, and a longer length of stay substantially increase the associated hospital costs. Prospectively monitoring individual patient treatment pathways beyond initial management is important when quantifying PJI treatment cost. Our study highlights the importance of optimizing initial surgical treatment, and informs treating hospitals of the resources required to provide care for PJI patients.

Design and cohort characteristics of TRACK, a prospective study of hyperkalaemia management decision-making.

Guideline-recommended hyperkalaemia management includes dietary potassium (K+) restriction, bicarbonate correction, diuretics and K+ binders with dose reduction of renin-angiotensin-aldosterone system inhibitors as a last resort. The extent to which these recommendations are implemented is uncertain, as real-world data on hyperkalaemia management are limited. The Tracking Treatment Pathways in Adult Patients with Hyperkalemia (TRACK) study is a multinational, prospective, longitudinal study that is being conducted to address this knowledge gap. We report the design and baseline cohort characteristics of this real-world study of hyperkalaemia management decision-making. This study enrolled participants within 21days of an episode of hyperkalaemia in four European countries (UK, Spain, Germany, Italy) and the USA. During the 12-month follow up, data collected will include participant and healthcare provider characteristics (specialty and practice setting), hyperkalaemia treatment objectives and strategies, rationale for management decisions and indicators of response and patient-reported perceptions of their hyperkalaemia treatment. The enrolled cohort includes 1330 participants, mean age 68years, of whom 31% were women. At baseline, 6% reported heart failure, 55% chronic kidney disease, 29% both and 9% neither. Most participants (57%) were taking an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker or angiotensin receptor/neprilysin inhibitor at baseline. Mineralocorticoid receptor antagonist use was lower (14%). The prospective TRACK study will shed light on practitioners' hyperkalaemia management decision-making and assess the impact of their decisions on hyperkalaemia recurrence. Understanding practitioners' underlying thought processes will facilitate efforts to improve hyperkalaemia management.ClinicalTrials.gov: NCT05408039.

A race against time – an evaluation of lifesaving treatment pathways for patients following cardiac arrest in a non-hospital setting.

BackgroundCardiac arrest occurs when the heart ceases pumping blood around the body. Most take place outside hospital. A sequence of effective interventions (a “chain of survival”) is essential for patient survival and recovery of organ function. Out of Hospital Cardiac Arrest (OHCA) requires prompt recognition and call for help, proficient CPR, early defibrillation and conveyance by the emergency services to an appropriate hospital. If initial resuscitation is successful, effective post-resuscitation care is required, delivered usually in the intensive care unit (ICU). New patient pathways were introduced following an update to national guidelines, which recommend conveyance of patients to centres with percutaneous coronary intervention (PCI) services where possible. ObjectiveWe have evaluated outcomes for patients, comparing those conveyed to PCI settings and those conveyed elsewhere to quantify the effect of the new patient pathway on mortality, survival and length of hospital stay. ApproachWe have linked electronic health records from emergency departments, acute hospital settings, ICUs and the national deaths register for OHCA patients living in Wales, UK. We have undertaken temporal analysis and time to event analysis to compare patient subgroups. ResultsVariation in patient pathways will be described using characteristics of conveyance method, the type of treating hospital and transfers between PCI and non-PCI settings adjusted for individual patient level confounders such as age, sex and comorbidities. ConclusionThis work is important to evaluate efficacy of operational procedures and inform national policies which aim to improve survival following OHCA and save lives.

Treatment Pathways in Patients With Crohn's Disease and Ulcerative Colitis: Understanding the Road to Advanced Therapy.

Patients with Crohn's disease (CD) or ulcerative colitis (UC) often cycle through conventional therapies (CT) with different mechanisms of action (MOA) before initiating advanced therapy (AT). We describe treatment patterns among patients with CD/UC. Using Merative MarketScan Research databases, adult patients with CD/UC were identified from medical/pharmacy claims (2017-2021). Patients had ≥1 hospitalization or ≥2 outpatient visits (≥30 days apart within 1 year) for CD/UC. Two cohorts were established; cohort 1: Newly diagnosed patients (index date is the date of first diagnosis) and cohort 2: Patients initiating AT (index date is the date of first AT). First-line treatment patterns (cohort 1) and CT pathways before AT initiation (cohort 2) by the number of episodes (ie, adding a new therapy, switching to another therapy, or restarting the same therapy after ≥60 days) and MOA are reported. Among newly diagnosed patients in cohort 1 (CD: n = 1739; UC: n = 2740), 14.4% (CD) and 5.9% (UC) of patients had any AT use during the follow-up period (mean: 2.3 years; ≥ 77% initiated corticosteroids). Among patients in cohort 2 (CD: n = 2594; UC: n = 2431), the mean number of CT episodes before AT initiation was 4.0 ± 4.3 (CD) and 5.9 ± 5.0 (UC). Among those with ≥1 corticosteroid episode (CD: 82.2%; UC: 91.5%), the mean number of episodes was 4.6 ± 4.3 (CD) and 6.3 ± 5.0 (UC). Overall, 13.3% (CD) and 23.7% (UC) of patients cycled through 3 MOAs before AT initiation. Despite treatment recommendations, few newly diagnosed CD/UC patients initiated AT as their first treatment. Moreover, patients cycled through multiple CTs before initiating AT.

Assessment and monitoring of lung disease in patients with severe alpha 1 antitrypsin deficiency: a european delphi consensus of the EARCO group

BackgroundCurrently, there is conflicting information and guidance on the effective management of Alpha 1 Antitrypsin Deficiency (AATD). Establishing a consensus of assessment and disease management specific to AATD is important for achieving a standardized treatment pathway and for improving patient outcomes. Here, we aim to utilize the Delphi method to establish a European consensus for the assessment and management of patients with severe AATD.MethodsTwo rounds of a Delphi survey were completed online by members of the European Alpha-1 Research Collaboration (EARCO). Respondents were asked to indicate their agreement with proposed statements for patients with no respiratory symptoms, stable respiratory disease, and worsening respiratory disease using a Likert scale of 1–7. Levels of agreement between respondents were calculated using a weighted average.ResultsRound 1 of the Delphi survey was sent to 103 members of EARCO and 38/103 (36.9%) pulmonologists from across 15 countries completed all 109 questions. Round 2 was sent to all who completed Round 1 and 36/38 (94.7%) completed all 79 questions. Responses regarding spirometry, body plethysmography, high-resolution computed tomography, and the initiation of augmentation therapy showed little variability among physicians, but there was discordance among other aspects, such as the use of low-dose computed tomography in both a research setting and routine clinical care.ConclusionsThese results provide expert opinions for the assessment and monitoring of patients with severe AATD, which could be used to provide updated recommendations and standardized treatment pathways for patients across Europe.

Dietary management and access to treatment for patients with glucose deficiency syndrome type 1: an overview review with focus on the European regulatory framework.

Glut-1 deficiency Syndrome (GLUT-1 DS) is a rare disease caused by a mutation in the SLC2A1 gene that codes for the glucose transporter protein GLUT-1 DS. Currently, there is no indicated drug therapy for this condition and ketogenic diet (KD) is the most effective remedy to treat it. The objective of this study was to review the published literature that evaluated the effectiveness of KD in the dietary management of GLUT-1 DS syndrome, describing the state-of-the-art the treatment pathway for patients with GLUT-1 DS syndrome in light of the current European regulatory framework within the National Health Services. The literature search was carried out on September 10, 2023, and all studies conducted in humans diagnosed with GLUT-1 deficiency syndrome and treated with KD were included. A total of 156 scientific papers have been extracted. Applying the exclusion criteria, 38 articles have been considered eligible. In 29 out of 38 studies, the main outcome for determining the efficacy of KD was the measurement of the number of epileptic seizures, demonstrating that patients treated with KD experienced improvements with a clear reduction in the number of epileptic attacks. Currently, in the European Union, only one country provides full reimbursement by the national health system for KD. Although they are crucial for the treatment of GLUT-1 DS, according with current food regulations, KD are not evaluated on the basis of an unambiguous efficacy result, but only on the basis of safety. As a result, it is desirable to carry out clinical studies in the coming years based on the determination of efficacy in target populations, also in view of the marketing of these products on the European market.

A UK multicentre audit of the management of patients with primary hypercholesterolaemia or mixed dyslipidaemia with bempedoic acid against published lipid-lowering treatment targets.

Bempedoic acid, an adenosine triphosphate citrate lyase inhibitor, was introduced to UK practice via a pre-reimbursement access scheme for adults with primary hypercholesterolaemia or mixed dyslipidaemia who are at high risk of cardiovascular disease, in whom statins are either not tolerated or contraindicated, who have not achieved target cholesterol, despite being on ezetimibe therapy, and do not qualify for PCSK9 inhibitor treatment. This retrospective multicentre audit aimed to evaluate the achievement of lipid-lowering targets with bempedoic acid in UK patients based on recommendations in the Joint British Societies (JBS) guidelines for the prevention of cardiovascular disease. Pseudo-anonymized medical record data for 221 adults treated with bempedoic acid as part of the UK scheme were entered into a bespoke data collection tool at four UK hospitals. Patient demographics, clinical characteristics, treatment pathways and lipid assessment results (against JBS lipid-lowering targets) were collected against pre-specified criteria. Overall, 54% (99/184) of patients achieved the JBS2 audit standard (total cholesterol (TC) <5 mmol/L and low-density lipoprotein cholesterol (LDL-C) <3 mmol/L or ≥25% reduction in TC and ≥30% reduction in LDL-C) at 12 weeks post-initiation. At week 12, the mean absolute change in LDL-C was -1.0 mmol/L; the mean percentage reduction from baseline was 22.0%. Additionally, 52% (96/185) of patients had an LDL-C of <3 mmol/L and 10% (18/185) an LDL-C of <1.8 mmol/L at 12 weeks (as per JBS3). This audit highlights the role of bempedoic acid as part of combination therapy for a population with previously limited treatment options.

Treatment pathways in patients with heart failure with preserved ejection fraction and obesity: perspectives from cardiology specialists and patients

Treatment pathways in patients with heart failure with preserved ejection fraction and obesity: perspectives from cardiology specialists and patients

Economic analysis of foregoing Rh immunoglobulin for bleeding in pregnancy

ObjectivesTo perform cost analyses of foregoing RhD blood type testing and administration of Rh immunoglobulin (RhIg) for bleeding in pregnancy at <12 weeks gestation in the United States. Study DesignWe created a decision-analytic model comparing the current standard treatment pathway for patients who have threatened, spontaneous, or induced abortion in the United States, with a new pathway foregoing RhD testing and administration of RhIg for those who are RhD-negative at <12 weeks gestation, assuming that the risk of sensitization is 0%. We derived population and cost estimates from current literature and calculated the number needed to treat, and number needed to screen, to avoid one case of fatal hemolytic disease of the fetus and newborn. We performed sensitivity analyses assuming Rh-sensitization risks of 1.5% and 3% and varying the subsequent pregnancy rates from 44-100%. ResultsThe annual savings to healthcare payers in the United States of foregoing RhD testing and RhIg administration to RhD-negative patients with bleeding events at <12 weeks is $5.5 million/100,000 total pregnancies, assuming that the risk of sensitization is 0%. In the sensitivity analyses with sensitization risk 1.5% and subsequent pregnancy rate 84.3%, foregoing Rh testing and RhIg administration <12 weeks would save $2.8 million/100,000 pregnancies, with a corresponding number needed to treat of 7,322 and number needed to screen of 48,816. At a 3% sensitization rate, the current standard treatment pathway is the most economical. ConclusionsThere is an opportunity to save the United States healthcare payers as much as $5.5 million/100,000 pregnancies by withholding RhIg in specific situations and conserving it for use later in pregnancy. ImplicationsCost analyses support foregoing RhD blood type screening and RhIg administration at <12 weeks gestation if the sensitization rate is <3%. By de-implementing this low value care, payers in the United States can save as much as $5.5 million/100,000 pregnancies and conserve RhIg for use later in pregnancy.

The Clinical and Economic Implications of Different Treatment Pathways for Patients With Rapidly Recurrent Malignant Pleural Effusion

BackgroundMalignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been fully evaluated. Research QuestionWhat clinical outcomes, complications, healthcare resource use, and costs are associated with various rapidly recurrent MPE treatment pathways? Study Design and MethodsThis retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients aged 66-90 with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis including non-definitive repeated thoracentesis, or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy. ResultsAmong 8,378 patients with MPE, 3,090 (36.9%) had rapidly recurrent MPE (mean [SD] age 75.9 [6.6], 45.6% male, primary cancer 62.9% lung and 37.1% other). Second pleural procedures were non-definitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was more frequently required if the second pleural procedure was non-definitive thoracentesis vs. chest tube, IPC, or thoracoscopy (70.3% vs. 44.1% vs. 17.9% vs. 14.4%, respectively). The mean number of subsequent pleural procedures over the patient’s lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P < .05). Average total costs following the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson Comorbidity Index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P < .0001) or chest tube ($40,627; P = .004) vs. thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P = .5) had similar costs to patients receiving thoracentesis. InterpretationEarly definitive treatment was associated with fewer subsequent procedures and lower costs in rapidly recurrent MPE.

Predictors of time to diagnosis and treatment: A retrospective cohort study of patients with clinically localized prostate cancer in Nigeria.

e23123 Background: Equitable access to the management of early-stage prostate cancer is important for optimal outcome in the diagnostic and curative treatment pathway of patients. This study aimed to identify the predictors of time to treatment and time to diagnosis in these patients. Methods: This was a cohort study of 110 patients with clinically localized prostate cancer (T1-T3a, N0, M0) in three government-funded tertiary hospitals in Nigeria. Retrospective data on sociodemographic status, co-morbid conditions, clinical, pathological and radiological quality metrics, date of first presentation for cancer-related complaint in the tertiary hospital, date of diagnosis of prostate cancer, and the date of commencement of first cancer-directed treatment were collected. Primary endpoint was the time from diagnosis to treatment and the secondary endpoint was the time from presentation to diagnosis. Predictors were determined by Cox proportional hazards using Stata software, version 18.0 with a p-value of less than 0.05 considered significant. Results: Twelve percent (n = 13) of the patients had a family history of prostate cancer. Fifty-four percent (n = 59) had other co-morbid conditions. Nearly one-third, 29% (n = 32) had retired from their primary occupation and 10% (n = 11) were covered by health insurance. The overall median time to diagnosis was 30 (interquartile range (IQR) 10 - 48) days. The median time to treatment commencement was 32 (IQR 19 - 82) days for ADT; 57 (IQR 50 - 63) days for active surveillance; 45 (IQR 21 - 78) days for radical radiotherapy; and 100 (IQR 0 - 127) days for radical prostatectomy. Diagnostic PSA documentation independently predicted delayed time to diagnosis (adjusted HR = 0.22 with 95% CI [0.05,0.97]) while those with guideline concordant imaging investigations independently predicted longer time to treatment (adjusted HR = 0.63 with 95% CI [0.40,0.99]). Conclusions: The documentation of PSA level and use of guideline concordant imaging investigations were significantly associated with delayed time to care. Studies on interventions to reduce barriers associated with these factors is warranted to strengthen equitable access to care in this setting.

Advancements in Cholangioscopy: A Case Report with a New Cholangioscope System and Review of Literature

AbstractThe field of cholangioscopy is undergoing rapid evolution, marked by continuous innovation. The advent of SpyGlass cholangioscopy has initiated a new chapter, transforming the practice with advancements that include single-operator procedures and the introduction of disposable cholangioscopes. Despite these strides, significant needs remain, including enhancement of optical imaging, improving maneuverability, and expansion of therapeutic channels. This article delves into the recent progress within cholangioscopy, with a particular focus on the clinical applications of the Leinzett Lan-EP-3516 cholangioscope for the management of portal biliopathy. We present a detailed case study demonstrating how this cutting-edge cholangioscope—distinguished by its various sizing options and compatibility with portable devices for immediate imaging—played an important role in the successful treatment of a distal common biliary duct stricture and choledocholithiasis. The device's cost-effectiveness and superior imaging quality signify a notable advancement in cholangioscopic technology, facilitating enhanced treatment pathways for patients with complex biliary disorders. This case exemplifies the dynamic and expanding utility of cholangioscopy in therapeutic interventions and underscores its escalating significance in clinical settings.

Real-world treatment patterns and medical costs of prostate cancer patients in Switzerland – A claims data analysis

BackgroundProstate cancer (PC) is the most prevalent cancer in men in Switzerland. However, evidence on the real-world health care use of PC patients is scarce. The aim of this study is to describe health care utilization, treatment patterns, and medical costs in PC patients over a period of five years (2014–2018). MethodWe used routinely collected longitudinal individual-level claims data from a major provider of mandatory health insurance in Switzerland. Due to the lack of diagnostic coding in the claims data, we identified treated PC patients based on the treatments received. We described health care utilization and treatment pathways for patients with localized and metastatic PC. Costs were calculated from a health care system perspective. ResultsA total of 5591 PC patients met the inclusion criteria. Between 2014 and 2018, 1741 patients had outpatient radiotherapy for localized or metastatic PC and 1579 patients underwent radical prostatectomy. 3502 patients had an androgen deprivation therapy (ADT). 9.5% of these patients had a combination therapy with docetaxel, and 11.0% had a combination with abiraterone acetate. Docetaxel was the most commonly used chemotherapy (first-line; n = 413, 78.4% of all patients in chemotherapy). Total medical costs of PC in Switzerland were estimated at CHF 347 m (95% CI 323–372) in 2018. ConclusionMost PC patients in this study were identified based on the use of ADT. Medical costs of PC in Switzerland amounted to 0.45% of total health care spending in 2018. Treatment of metastatic PC accounted for about two thirds of spending.

Acupuncture and tuina knowledge graph with prompt learning.

Acupuncture and tuina, acknowledged as ancient and highly efficacious therapeutic modalities within the domain of Traditional Chinese Medicine (TCM), have provided pragmatic treatment pathways for numerous patients. To address the problems of ambiguity in the concept of Traditional Chinese Medicine (TCM) acupuncture and tuina treatment protocols, the lack of accurate quantitative assessment of treatment protocols, and the diversity of TCM systems, we have established a map-filling technique for modern literature to achieve personalized medical recommendations. (1) Extensive acupuncture and tuina data were collected, analyzed, and processed to establish a concise TCM domain knowledge base. (2)A template-free Chinese text NER joint training method (TemplateFC) was proposed, which enhances the EntLM model with BiLSTM and CRF layers. Appropriate rules were set for ERE. (3) A comprehensive knowledge graph comprising 10,346 entities and 40,919 relationships was constructed based on modern literature. A robust TCM KG with a wide range of entities and relationships was created. The template-free joint training approach significantly improved NER accuracy, especially in Chinese text, addressing issues related to entity identification and tokenization differences. The KG provided valuable insights into acupuncture and tuina, facilitating efficient information retrieval and personalized treatment recommendations. The integration of KGs in TCM research is essential for advancing diagnostics and interventions. Challenges in NER and ERE were effectively tackled using hybrid approaches and innovative techniques. The comprehensive TCM KG our built contributes to bridging the gap in TCM knowledge and serves as a valuable resource for specialists and non-specialists alike.

The importance of interdisciplinary communication in the neck lump clinic to improve efficiency and diagnosis in an unusual lymphoma presentation

The importance of close and collaborative working between surgeons and radiologists in a one stop neck lump clinic is essential to ensure the correct diagnosis and treatment pathway for patients. Here we present an unusual presentation of lymphoma which demonstrates how a cancer diagnosis can be made without delay even with conflicting clinical and radiological findings, when colleagues are able to direct liaise in a one stop clinic.

Feasibility of a web-based and mobile supported follow-up treatment pathway for adult orthopedic trauma patients in the Netherlands: a concurrent mixed-method study (Preprint)

Feasibility of a web-based and mobile supported follow-up treatment pathway for adult orthopedic trauma patients in the Netherlands: a concurrent mixed-method study (Preprint)